Unique Plan Description: MFM Fetal Anomaly Consult Clinic
Plan Selection Display: MFM Fetal Anomaly Consult Clinic
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-03-19 16:58:57
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-04-18 08:33:26
Available at all facilities: Yes

MFM Fetal Anomaly Consult Clinic
Laboratory
Amniotic Fluid Testing
	UNMC Reproductive Chromosome Rflx to FISH
		T;N, Routine, spec type = Amniotic Fld
General Labs
	Cystic Fibrosis (CFTR) Variant Panel (PreAuth Req)-2013661
		T;N, Routine, spec type = Blood
	Hemoglobin A1C
		T;N, Routine, spec type = Blood
	Parvovirus B19 Ab IgG and IgM
		T;N, Routine, spec type = Blood
	Thyroid Panel
		T;N, Routine, spec type = Blood
	Toxoplasma IgG and IgM
		T;N, Routine, spec type = Blood
	CMV Antibodies IgG and IgM
		T;N, Routine, spec type = Blood
Medications

	RHo (D) immune globulin 300 mcg (In Office)
		1,500 intl_units, Solution, IM-Intramuscular, Once, NOW
Consults/Follow-up
	Follow-up Appointment
		Follow Up Visit, 2 weeks
		Follow Up Visit, Today
		Follow Up Visit, 1 month
		Follow Up Visit, 3 months
		Follow Up Visit, 6 months
		Follow Up Visit, 1 week
		Follow Up Visit, 3 weeks
		Follow Up Visit, 6 weeks
		Follow Up Visit, PRN
		Follow Up Visit, See Special Instructions
	Request for Service
		
	Surgery to Schedule
		
	Consult Other
		
Charges/Supplies
Est. Pt Visit
	99211 EVM - OP visit estab patient, minimal care < 10 min
		T;N
	99212 EVM - OP VISIT ESTAB PATIENT, STRAIGHTFORWARD 10 MIN
		T;N
	99213 EVM - OP VISIT ESTAB PATIENT, LOW LEVEL 20 MIN
		T;N
	99214 EVM - OP VISIT ESTAB PATIENT, MODERATE 30 MIN
		T;N
	99215 EVM - OP VISIT ESTAB PATIENT, HIGH LEVEL 40 MIN
		T;N
New Pt Visit
	zz99201 EVM-New Pt Visit Problem focused 10m
		T;N
	99202 EVM - OP VISIT NEW PATIENT, STRAIGHTFORWARD 15 MIN
		T;N
	99203 EVM - OP VISIT NEW PATIENT, LOW LEVEL 30 MIN
		T;N
	99204 EVM - OP VISIT NEW PATIENT, MODERATE LEVEL 45 MIN
		T;N
	99205 EVM - OP VISIT NEW PATIENT, HIGH LEVEL 60 MIN
		T;N
Procedures in Office
	59000 CP Amniocentesis, diagnostic MFM
		Anomalies, Additional Fetus 0
		Anomalies, Additional Fetus 1
		Anomalies, Additional Fetus 2
		Anomalies, Additional Fetus 3
	Fetal Non-Stress Test
		
	76801 US Abdominal <14 Wks (in office)
		Anomalies, Additional Fetus 0
		Anomalies, Additional Fetus 1
		Anomalies, Additional Fetus 2
		Anomalies, Additional Fetus 3
	Level 1 U/S (in office)
		Anomalies, Additional Fetus 0
		Anomalies, Additional Fetus 1
		Anomalies, Additional Fetus 2
		Anomalies, Additional Fetus 3
	76811 Level II U/S  -MFM
		Anomalies, Additional Fetus 0
		Anomalies, Additional Fetus 1
		Anomalies, Additional Fetus 2
		Anomalies, Additional Fetus 3
	76816 US OB Follow-up (in office)
		Anomalies, Additional Fetus 0
		Anomalies, Additional Fetus 1
		Anomalies, Additional Fetus 2
		Anomalies, Additional Fetus 3
	76815 US OB Limited (in office)
		Anomalies, Additional Fetus 0
		Anomalies, Additional Fetus 1
		Anomalies, Additional Fetus 2
		Anomalies, Additional Fetus 3
	76819 US Fetal Biophys w/o Stress (in office)
		Fetal Anomaly, Additional Fetus 0
		Fetal Anomaly, Additional Fetus 1
		Fetal Anomaly, Additional Fetus 2
		Fetal Anomaly, Additional Fetus 3
	76818 US Fetal Biophysical Profile (in office)
		Fetal Anomaly, Additional Fetus 0
		Fetal Anomaly, Additional Fetus 1
		Fetal Anomaly, Additional Fetus 2
		Fetal Anomaly, Additional Fetus 3
	76817 US OB Transvaginal (in office)
		Anomalies
	76827 Doppler (in office)
		Anomalies, Additional Fetus 0
		Anomalies, Additional Fetus 1
		Anomalies, Additional Fetus 2
		Anomalies, Additional Fetus 3
	76828 Doppler F/U (in office)
		Anomalies, Additional Fetus 0
		Anomalies, Additional Fetus 1
		Anomalies, Additional Fetus 2
		Anomalies, Additional Fetus 3
	93770 Ductus Venosus (in office)
		Anomalies, Additional Fetus 0
		Anomalies, Additional Fetus 1
		Anomalies, Additional Fetus 2
		Anomalies, Additional Fetus 3
	76825 Doppler Echo, Fetal, 2D (in office)
		Anomalies, Additional Fetus 0
		Anomalies, Additional Fetus 1
		Anomalies, Additional Fetus 2
		Anomalies, Additional Fetus 3
	76826 Doppler Echo, Fetal F/U (in office)
		Anomalies, Additional Fetus 0
		Anomalies, Additional Fetus 1
		Anomalies, Additional Fetus 2
		Anomalies, Additional Fetus 3
	76820 Doppler Umb Artery (in office)
		Anomalies, Additional Fetus 0
		Anomalies, Additional Fetus 1
		Anomalies, Additional Fetus 2
		Anomalies, Additional Fetus 3
	76821 Doppler Mid-Cerebral Artery (in office)
		Anomalies, Additional Fetus 0
		Anomalies, Additional Fetus 1
		Anomalies, Additional Fetus 2
		Anomalies, Additional Fetus 3
	93976 Doppler Uterine Artery (in office)
		Anomalies

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase